Dr. Asadur J. Tchekmedyian

Montevideo - Uruguay

asadurjorge@gmail.com

• Abdominal pain

• Changes in bowel habits

• Colon cancer screening

• Difficulty in swallowing

• GI bleeding

Symptoms that point to a condition or disease involving the digestive system.

• Jaundice

• Persistent constipation or diarrhea

• Persistent heartburn

• Persistent nausea or vomiting

• Rectal pain or bleeding

Worried about the GI health….. (stomach / colorectal cancer)!!

• GI diseases affect 70 million people annually

• 4.6 million hospitalizations

• 72 million ambulatory care visits

• Spendings : 142 BILLION per year

Just in the USA….

R Jones. Postgrad Med J 2008;84:454-458

• Gastrointestinal cancers, taken together, make up the largest group of malignancies.

• Approximately 10% of consultations in general practice in the UK are for

gastrointestinal symptoms or problems.

• Gastroenterology represents about 10% of the work of hospital specialists.

• Prescribing costs involved in the management of gastrointestinal disorders in general

practice are around 14% of the drug budget.

Digestive Procedures With More Than a 10% Change Over 3 Years

• CT colonography (virtual colonoscopy)

• Whole-Body CT SCAN

• Abdomen CT SCAN

• Abdomen x-ray

• Upper GI tests (Barium swallow. Upper GI series. Small bowel series)

• Lower GI Tests (Barium enema with/without air contrast

• ERCP

• Nuclear Medicine

• PET

X-Ray Exams of the Digestive Tract

X-Ray Exams of the Digestive Tract

• CT colonography (virtual colonoscopy)

• Whole-Body CT SCAN

• Abdomen CT SCAN

• Abdomen x-ray

• Upper GI tests (Barium swallow. Upper GI series. Small bowel series)

• Lower GI Tests (Barium enema with/without air contrast

• ERCP

• Nuclear Medicine

• PET

Medicine VS Marketing

Patients VS Clients

In fact, as whole body CT is being marketed directly to consumers, the consumers (patients) are now beginning to demand the test.

College of Radiology, Academy of Medicine of Malaysia Position on Whole Body Screening CT scans in Healthy Asymptomatic Individuals

July 2008

1.how often your patients ask you for a CT SCAN or other Rx exam (PET, etc) for an individual evaluation without clinical indication?

2. In which sets you will agree to order an exam that uses X Rays (CT scan, etc) to an asymptomatic individual (not as part of screening or surveillance).

A. frecuently

B. esporadically

C. never

“If the lawyer wants”

Almost never!!

Not formal, not randomized, uncontrolled and friendly trial!

Individual Health Assessment (IHA)

Risk perception / Risk management

“FDA has not approved or cleared CT systems for any application or indication that involves “screening of individuals” who do not have symptoms or other high risk factors.

The American College of Radiology “does not believe there is sufficient scientific evidence to justify recommending total body computed tomographic (CT) screening for patients with no symptoms or a family history suggesting disease.”

American Association of Physicists in Medicine (AAPM): CT Body Scanning Not Scientifically Justified for Asymptomatic Patients.

“The bottom line is, until we have specific evidence that these studies are beneficial to the asymptomatic population, they should not be done”

Garth A. Koniver, MD, FACR, August, 2002

Individuals with a high risk of developing colorectal cancer should be managed as part of a comprehensive programme.

It is inappropriate for such patients to be investigated in commercial scanning centres.

Is CT colonography (virtual colonoscopy) the “holy grail” in the IHA?

NO

11.870 CTC 7 perforations (0,06%)

(that’s more than in screening optical colonoscopy)

No pain?

No colon preparation?

No risk?

NO

NO

Sosna J, Blachar A, Amitai M, et al. Assessment of the risk of colonic perforation at CT colonography in a multi-center large cohort. Radiology 2006; 239:457–463

Virtual Colonoscopy

J Roberts, S Keene. Asymptomatic CT Scans: A Health Assessment or a Health Risk?. The Internet Journal of Radiology. 2007 Volume 9 Number 1.

Despite the good intentions, more harm is often inflicted with these scans.

false sense of security,

out of pocket costs, and

unnecessary radiation exposure.

Roberts, 2009.

early detection

prevention

peace of mind.

Kolata, 2005

Supporters Opponents

American Journal of Law & Medicine, Vol. 20, pp. 105-128, 1994

“All the tests are too inaccurate for screening in low-risk populations, and

none has been proven to lead to early, beneficial intervention.”

No (at least yet).

Is CT colonography (virtual colonoscopy) the “holy grail” in the IHA?

Doctor–Patient Relationship

The best way to bring “peace of mind” is a good relationship!

As Chairman Mao said, the first step in solving a problem is calling it by its right name*.

*Dorr Goold S. The Doctor–Patient Relationship. 1999;14(Suppl 1):S26–S33. Mao Tse Tung. Quotations from Chairman Mao. San Francisco, CA: China Books; 1975.

Cost 0, no risk,

Guaranteed: 100 % “customer” satisfaction!

Thank You!!

asadurjorge@gmail.com

"Scanning an asymptomatic person is a fishing expedition. For every abnormal entity found, there may be 100 more. It does no more than make patients anxious. The bottom line: It's a bad idea to reassure patients inappropriately, and it's a bad idea to give information that's not helpful. Scans should only be done for clinical indications.“ Michael Grodin Director of the Law, Medicine and Ethics Program at BU. Cited by: Dorothy Pennachio. Full-body scans--or scams?. Medical Economics 2002;15:62